Nursing technicians’ professional training in patient safety: A mixed-methods study

Abstract Objective: to analyze nursing technicians’ training in patient safety. Method: a convergent parallel mixed-methods study, where qualitative and quantitative elements were concomitantly implemented and equally prioritized, carried out in three technical colleges linked to a federal public institution in the Brazilian Northeast region. In the qualitative phase, semi-structured interviews were conducted with 24 professors and thematic analysis was applied. In the quantitative study, of the survey type, an instrument was used to screen terms about patient safety with 84 students. The results were combined during the general data interpretation, which was based on the Patient Safety Curricular Guide. Results: two thematic categories emerged: The professors’ understanding about the theme of patient safety in nursing technicians’ training; and Application and projection of the teaching of patient safety in nursing technicians’ training. In the quantitative study, among the 46 screening terms, their identification in the theoretical-practical context predominated in Courses A and C, totaling 36 (78.3%) and 25 (54.3%), respectively. Theoretical teaching stood out in Course B, with 26 terms (56.5%). Conclusion: professional training of Nursing Technician students has a technical focus and does not fully contemplate patient safety issues in the teaching-learning process and, thus, constitutes a challenge for training institutions and professors alike.


Introduction
In the last decades, the issues associated with patient safety became one of the priority subject matters in the health area at the global level. In this context, the World Health Organization (WHO) suggested the reform and inclusion of content on this topic in the curricula of health courses (1)(2) , culminating in 2011 with the launch of the Patient Safety Curricular Guide for Multiprofessional Health Education (Guia Curricular de Segurança do Paciente para o Ensino Multiprofissional de Saúde, GCSPEMS) (3) .
Inclusion of this topic in the curricula involves building a safety culture aimed at reducing errors, equipping future professionals to deal with risks and develop skills to strengthen health systems (4)(5) .
This multiprofessional edition encompasses Dentistry, Medicine, Obstetrics, Nursing, Pharmacy and other professions included in the health team. Although it was developed to be integrated into undergraduate curricula, it can be applied to different cultures and contexts, such as technical Nursing education, based on specific adaptations to the local requirements and parameters, as well as to the students' resources and pedagogical needs (3) .
Technical-level Nursing professionals perform almost all their activities in close contact with the patients. It is for this reason that their training needs to be solid, with the required technical and human skills for an adequate development of the professional practice (6) . Direct and constant contact with the patients turns them more susceptible to the occurrence of events associated with errors in the health care practice (7) .
In Brazil, the first Nursing technical school emerged in the 1960s. Political, social and economic changes during this period exerted a major influence on Brazilian Nursing mobilizations and questions. While nurses were concerned with consolidating this profession as essential for the health sector, the federal government made efforts to increase industrial production and deal with the financial crisis. Therefore, there was the need for an educational reform, which favored creation of the Nursing Technician course (8) .
There was perpetuation of a scenario in which nursing technicians' training was associated with an emphatic appreciation of specific knowledge targeted at sustaining the capitalist production mode (9) . Over time, vocational technical education was the object of new and profound changes, with enactment of the Education Guidelines and Bases Law (Lei de Diretrizes e Bases da Educação, LDB) (Law No. 9,394/96) and Federal Decree No. 2,208/97, incorporating the proposal to modernize vocational education in the country (10) . Subsequently, the National Curricular Guidelines for Technical-Level Professional Education were instituted, centered on the commitment to the development of professional competencies (11) .
Despite the growing structuring of technical education in Brazil, the specificity of the organization of Nursing in different professional categories and the expressive participation of nursing technicians in the team indicate that the issue of training these professionals is complex, imposing the choice of central aspects that allow understanding training itself (9) , in search of patient care qualification.
Given this situation, it is verified that Nursing technical training in Brazil has shown a number of weaknesses. Nursing technical courses increasingly display extremely fast and low quality training, contributing to the inclusion on unqualified professionals into the labor market (12) . As a limitation, this teaching has presented as a hegemonic approach aimed at carrying out technical procedures (13) , with requirements of the instrumental training principles, guided by a technical educational project and by lack of reflection on the individual/social reality and on action (14) . Training that goes against the need for professional nursing technicians, in addition to having technical skills, to have a technical-scientific framework for the benefit of good care practices, aiming at reducing adverse events (5) .

This very insufficiency related to Nursing technical
training is observed in the international context. Costly adverse patient outcomes, including pressure injury, falls with injuries, and urinary tract infections, are less frequent in hospitals with a higher proportion of undergraduate versus technical-level Nursing professional (in some countries, such as United States of America and Canada, called "nurse practitioners") (15) . In the Brazilian context, a study that evaluated the Pedagogical Project (PP) of technical Nursing courses revealed gaps in the training of these professionals, with an implicit, punctual and disjointed approach to the contents related to patient safety (16) . Therefore, the discussion regarding teaching of this topic in the Nursing technical course is urgent for good quality training, so as to exert a direct impact on the health actions. Thus, the following question was selected to guide the research: How is patient safety addressed in nursing technicians' training? The objective was to analyze nursing technicians' training in patient safety.
prioritized (QUAN + QUAL) and kept independent during the analysis process, with combination of the results during interpretation general. The QUAL data were obtained from interviews with the professors and the QUAN data, from applying the questionnaires to the students. Using procedures that implement qualitative and quantitative components concurrently in different samples aims at understanding multiple perspectives on a single issue (17) . By using different samples, it was sought to understand, among other aspects, the contradictions between qualitative and quantitative findings (18) .
The report followed the recommendations set forth in the Guideline Consolidated Criteria for Reporting Qualitative Research (COREQ) (19) for the qualitative stage and in Strengthening the Reporting Observational Studies in Epidemiology (STROBE) for the quantitative stage (13) .

Locus
The study was carried out in three technical Nursing

Period
The qualitative and quantitative data collection procedures were performed concomitantly from June to December 2019.

Population
The qualitative stage was comprised by professors and the participants in the quantitative stage were students attending all three Nursing Technician courses. It was decided to approach different populations, considering that the professors assume the commitment in nursing technicians' training and, thus, they know the politicalpedagogical approach of the course to which they are linked; and, on the other hand, the students can in fact inform and recognize how patient safety is employed, either in theory or in practice, during the training process.

Selection criteria
The following inclusion criteria were defined for the qualitative stage: being an effective and temporary professor, active in technical courses; with at least six months performance; and responsible for academic disciplines in which one or more terms related to patient safety were found in the curricula, identified in a previous study (16) . The following exclusion criteria were established: professors who did not return contact after three attempts, on different days and times; and those on maternity or sick leave, although there was no need to apply this latter.
The following was defined a inclusion criterion for the quantitative stage: being a student regularly enrolled from the third period in one of the three courses, considering that, at this stage, contact with the academic disciplines and internships allows for a better position on the training process. Students who suspended enrollment were excluded, as well as those on maternity or sick leave.

Definition of the participants
In the qualitative stage, the sample was defined for convenience, according to the professors' availability for data collection in the study loci. In total, all three courses have 28 faculty members. To recruit the target population, the researchers held face-to-face meetings with the coordination of the courses and, subsequently, with the professors, presenting objectives, methods, risks and intended benefits. During the recruitment phase, four individuals refused to participate in the research due to time unavailability, which totaled a sample comprised by 24 participants. In order to preserve anonymity and observing the ethical issues, code P (Professor) was employed, followed by an Arabic number corresponding to the order in which the interviews were conducted (P1, P2... P24).
In the quantitative stage, the sample was of the census type, inviting students able to participate. After to present the study proposal and, at that moment, the date, time and place for data collection were agreed upon with those involved. From the universe of 86 possible participants, 84 students comprised the final sample of this stage.

Instruments used for data collection
A form on sociodemographic and professional aspects, as well as those related to patient safety, was applied in the qualitative stage. The interview script had the following guiding question: How is patient safety addressed in nursing technicians' training? A pilot test was previously performed with two Nursing professors from other mid-level institutions: such test indicated that some of the script questions needed to be corrected.
These interviews did not comprise the final sample data.
In the quantitative stage, a questionnaire was used to characterize the students' sociodemographic aspects and knowledge about patient safety. A previously validated instrument was also employed, structured in eight domains and 46 items (screening terms), to assess the training context (theory) and performance in the internships (practice), in the context of patient safety (20) .
The domains that comprise the instrument are as follows: what is patient safety?; reasons why applying human factors is important for patient safety; effective team; learning from errors to avoid harms; use of good quality methods to improve the assistance provided; medication safety; interaction with patients and caregivers; and prevention and control of infections. The instrument has an adjectival scale to answer in which context they had contact with a screening term: theoretical or practical; only one of them; or none (20) .
This instrument was prepared to assess the curricula of Nursing undergraduate courses. The decision to apply it in technical course curricula was motivated by the analysis of the items that make up the domains that also apply to this level of education. In addition to that, application in this study expands the use possibilities of the aforementioned instrument.

Data collection
Data collection was in charge of two previously In the qualitative stage, an approach was first made in order to justify the interviewer's interest in the topic and, consequently, the drivers to conduct the research. The interviews were conducted in a private space, in a room offered by the HEI, according to the interviewees' availability and with the presence of at least of the researchers. After prior authorization, they were audio-recorded in a digital voice recorder. The interviews lasted between 20 and 60 minutes. The information was validated in terms of content by the participants who, at the end of the interview, were asked if they would like to add anything to the reports. The data obtained were stored for full transcription with the aid of the Microsoft Word ® program. No interviews were repeated.
In the quantitative stage, data collection was carried out in a private classroom, collectively, with delivery of the instruments in a sealed envelope to each student, who answered individually and with a flexible deadline.

Study variables
The study variables established from the quantitative stage consisted of eight domains and the respective 46 screening terms that comprise the instrument for evaluating the training context (theory) and performance in internships (practice), in the scope of patient safety: 1.
What is patient safety?; 2. Reasons why applying human factors is important for patient safety; 3. Effective team; 4. Learning from errors to avoid harms; 5. Use of good quality methods to improve the assistance provided; 6. Medication safety; 7. Interaction with patients and caregivers; and 8. Prevention and control of infections (20) .

Data treatment and analysis
The qualitative data analysis was based on the Thematic Analysis framework (21) , consisting of three stages: pre-analysis, data transcribed by the researcher into text files, to assemble the study corpus; floating readings, to understand the text based on the study objectives; and their aggregation into topics, with description and representation of excerpts from the corpus. The meanings that emerged enabled interpretation, according to the objectives proposed and leaving room for an in-depth discussion (21) .
The quantitative data analysis was performed in the Statistical Package for the Social Sciences statistical software program (version 21.0). In order to interpret the data related to the number of triggering terms referenced by the students, according to the context in which knowledge about the patient safety contents was obtained, the parameter of values above or below 50% was used to classify the findings of the instrument to identify cognitive and curricular attributes (20) .
Finally, the researchers used the convergent design to compare the findings from qualitative and quantitative www.eerp.usp.br/rlae 5 Rocha RC, Avelino FVSD, Borges JWP, Araújo AAC, Bezerra MAR, Nunes BMVT. data sources. For this purpose, the diverse information was evaluated using parallel constructions for both types of data, which allowed providing validation for each other and creating a solid basis for conclusions about nursing technicians' training from the perspective of patient safety (17) . Interpretation of the QUAL+QUAN was performed in the light of authors that dealt with training in Nursing and Patient Safety and according to the GCSPEMS guide (22) .

Ethical aspects
The research was approved by the Research Ethics

Results
The participants were 24 professors and 84 students from all three Nursing Technician courses. Regarding  In the same direction, the results of the QUAN study show that, in Domain 1 (What is patient safety?), the "Patient safety notions" and "Patient-centered care" items were addressed in 89.0% and 92.7% of the cases, respectively, of the theoretical-practical classes in the courses under study, which indicates the students' consistent approach to conceptualization of the theme. Regarding Domain 3 (Effective team), the "Interdisciplinary/Health team" item, which was also highlighted in the professors' statements for safe care, obtained investment of classes in approximately 60.2% in the theoretical-practical context (Table 1).
However, in the same domain, the "Errors involving human, environmental and/or organizational factors" item, which can involve use of institutional protocols, was only addressed, on average, in 49.9% of the theoreticalpractical classes. In addition, it is interesting to note that, in Domain 5 (Use of good quality methods to improve the assistance provided), both the "Care quality indicators" and the "Quality improvement" screening items were below 60% in the theoretical-practical and theoretical approaches ( Following the same direction, the students indicated that the "Errors/Types of errors" item from Domain 4 (Learning from errors to avoid harms) was addressed in more than half of the theoretical-practical classes (57.3%), despite significant variability between the courses (from 86.7% to 40.7%), as well as the "How to learn from errors" item, whose mean was 56.2% (varying from 83.3% to 33.3% between the courses). With a lower mean, the "Notification about errors" item was indicated by the students as addressed in nearly 49.2% (varying between 70% and 37%) of the theoretical-practical classes. It is even more worrying that the "Blame culture", an item from Domain 1 and which deals with the omission and/or concealment of errors made in patient care, was only discussed in 19% of the theoretical-practical classes.
In the second category, the professors reported that the topic is treated in a theoretical and/or practical The professors also stated that the theme of patients' rights and duties is a frequently alluded subject matter in Nursing technical teaching, mainly in the "Nursing Fundamentals" discipline. These findings diverge from the quantitative stage data, as a reduced percentage of students (36.3%) stated having theoretical-practical knowledge about health system users' laws and rights.
Although the Pharmacology discipline was mentioned by the professors as a place of allusion to the aspects related to patient safety, with an indication also by the students in the QUAN stage that the "Medication system and drug prescription, distribution and administration processes" item was included in 85.4% of the theoreticalpractical classes, it was verified that "medication errors" were represented in less than half of the mentions (45.2%) of the theoretical-practical classes (Table 1).
According to the professors, although the topic of patient safety has gained space in recent years, the need for a more targeted approach emerges, in order to motivate and include students in these contents, with participation in events dealing with this theme. They also highlighted indispensability of the content in a visible way in the PP, as the importance of the topic is unquestionable, given the statistical data of errors and harms in health care.
During the interviews, there was a projection of professors regarding issues related to patient safety, emphasizing what can be improved to leverage teaching on the subject matter in nursing technicians' training. In their statements, the professors highlighted the need to work on the topic more consistently, especially in the theory, as some participants reported that they felt more comfortable exploring this topic in the practice. The professors also agreed that they did not feel properly prepared to conduct this subject matter in the classroom and, therefore, www.eerp.usp.br/rlae 7 Rocha RC, Avelino FVSD, Borges JWP, Araújo AAC, Bezerra MAR, Nunes BMVT.

Discussion
Despite being considered a new science, inclusion of the contents on patient safety is still presented as a recent proposal in educational institutions (23) , recognizing that it is challenging to incorporate any new content into a curriculum, especially when it comes to this theme, which requires addressing countless subject matters that are not traditionally taught to students in the health area, such as human factors, systemic reflection, teamwork and error management (4,22,24) . This situation is verified in performance of the interpretation of the entire analysis, when it is identified that, although the students recognize the allusion to the theoretical aspects about some elements of the topic, other points, of greater complexity and multidisciplinary approach, need to be deepened.
It is verified that, as in other contexts of Nursing training, patient safety adopts a predominantly technical approach, which can compromise patient safety, which has been challenged by some factors, including lack of creativity, inadequate professional competence, lack of judgment and decision-making ability, insufficient knowledge and skill in care, and lack of effort to improve professional skills (25) .
Patient safety is relevant in several teaching areas, including Nursing teaching and practice. As well as other members of the health team, technical Nursing have the opportunity of improving patient safety quality. In this sense, professors play a vital role in improving the knowledge required from the students, as well as their attitude and perception towards patient safety. They can ensure that the students are prepared to provide a safe environment and to care for the patients (26) . It is therefore essential to promote students' knowledge and skills in non-technical issues, including patient safety, in order to increase their ability to deal with the challenges they encounter in clinical environments (27) .
The "blame culture" was identified in the professors' reports, when they showed concern about the occurrence of errors from the perspective of professional failure, when reporting the fear of errors being broadcast in the media, instead of seeing them as opportunities to improve the system. This teaching attitude was reflected in the results of the quantitative study, where the "Blame culture" item was presented as the most unknown term by the students, confirming that this issue must be explored effectively in the three courses under study. The fact that the students claim not having had the necessary contact with this concept contributes to the continuity of a system of punitive ideas in the face of failures, not giving them the opportunity to understand the error as an opportunity to learn, as well as to develop skills to avoid them (28) .
The blame culture should be substituted with a fair culture within the care environments. Some health services even discuss errors in an individualized way, in which penalties are applied to the person responsible for an error, which presupposes a false resolution of the problem, triggering various consequences for the professional involved. Errors should be systematically disclosed, motivating the professionals to see them as part of the system and, thus, seek to remove the factors that contribute to that (29)(30) .
Application of the patient safety topic in nursing is incipient (31) .
In their reports, the professors indicated the importance of teamwork, in a multiprofessional modality, and emphasized the nursing technicians' role in the health team for their performance in terms of safety.
Approximations were identified in the quantitative stage, where it was evidenced that the professors applied these concepts with a theoretical-practical approach in the classes. The multidisciplinary aspect is a positive factor in the courses studied, in which teamwork, based on collective action, represents a reciprocal relationship between the multiple technical interventions and the interaction of agents from different professional areas (32) .
For this, it is necessary to establish dialog between the members, open communication about errors, and openness for satisfactory interpersonal relationships (33) . study, which indicated the consistent theoretical-practical approach of this theme, confirming the importance of this item for safe care.
The professors' concern in addressing this issue is due to the fact that the errors resulting from the drug therapy represent a growing and challenging problem, in addition to being one of the most common types of incidents in health facilities, which can occur at any of the stages (7,(34)(35) .
A retrospective and correlational study, conducted in collaboration with a system of community hospitals and with the objective of analyzing the relationship between the Nursing team and the occurrence of medication  (15,37) .
The strategies related to the prevention and control of Healthcare-Associated Infections (HAIs) were mentioned by the professors as an aspect that would need to be advanced in the training process, and which must be dealt with in depth in the nursing technicians' training due to their high rates. This finding corroborates data from the quantitative study, in which most students reported having only theoretical knowledge (51.5%) on the subject matter, which can refer to the need for them to be better disseminated in the practical activities ( Table 1).
The strategies to prevent and control infections should be expanded to all health care settings, and this first and foremost permeates the professionals' training (38)(39)(40) . In this direction, the teaching of patient safety, related to infection control, should integrate the curriculum of Nursing courses, as well as be covered by research and extension activities and explored in greater depth, providing practical activities relevant to the professional practice (40) .
Also in this sense, the professors emphasized hand hygiene, associated with the activities developed in the internships and in the specific academic disciplines. In the quantitative study, this screening term was learned by most of the students in the theoretical-practical context. Hand hygiene has proven efficacy in minimizing the microbial load, preventing and controlling crosstransmission by microorganisms, being considered a strong indicator of care quality in terms of patient safety (41)(42)(43) . Despite the vast dissemination of diverse information regarding effectiveness of hand hygiene as a means to prevent HAIs, adherence is still insufficient, as 70% of the health professionals do not perform the practice following the proper technique and at appropriate times (2,44) .
A study conducted with health professionals working in a Neonatal Intensive Care Unit from state of Bahia,

Brazil, verified that the team of nursing technicians
consisted of the population that presented the lowest adherence rate to hand hygiene (45) . Consequently, it is recommended to adopt efficient and continuing educations training measures, as well as to improve the offer in terms of supplies, in order to promote adherence among these professionals. Therefore, the students attending the technical course should be duly qualified during their training, so that the put proper hand hygiene into practice when they provide care.
The topic of processing contaminated articles was mentioned by the professors as one of the ways to provide safe care, citing the sterilization principles as fundamental for preventing patient contamination. This item was found in the quantitative study. Thus, it is understood that, in addition to adding quality to Nursing care, good practices in the processing of instrumental articles for health provide safety for the users and professionals involved (2,46) .
The comparison between the context in which the screening terms were cited (theory and practice, theoretical classes and practical teaching) and the course It is considered that this study was limited by the scarcity of research studies that specifically addressed students' training in technical Nursing courses for patient safety.

Conclusion
When analyzing the intersections of professional training in the teaching perspective and student On the other hand, in a movement of convergence and some divergences with the teaching perspective, the students also recognize that the technical Nursing courses did not cover the topic in its entirety. Although the professors did not criticize the technical and procedural training that focuses on safe care aspects only related to the know-hows, the students indicated a limited approach that fails to address the comprehensive training needs of the nursing technicians' work in the Brazilian reality, involving, in addition to technical implementation, planning and development of reflective, comprehensive and, consequently, safe care.
Aspects of a merely theoretical approach or that have not been identified need to be improved, so that they are known and explored by the students, with emphasis on the absence of an approach to the blame culture. Nursing technicians' training showed not to fully contemplate patient safety issues in the teaching-learning process, representing a challenge for institutions and professors alike.